Basic Information
| Provider Information | |||||||||
| NPI: | 1790797116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGENBACH | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 SCHOOL ST | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028605747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4016162000 | ||||||||
| FaxNumber: | 4016162001 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 ROUTE 30 N | ||||||||
| Address2: | |||||||||
| City: | BOMOSEEN | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057329647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024685641 | ||||||||
| FaxNumber: | 8024682923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 10/05/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001695 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 055-0031268 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.